Is it sexual abuse? Confusion caused by a congenital anomaly of the genitalia

Because of the increasing number of reports of sexual abuse of children, pediatricians should become more familiar with the examination of the genitalia of prepubertal children and learn to recognize physical indicators of abuse. Although some physicians may not recognize abnormal findings on examination, in other cases, unusual physical findings may be reported erroneously as possible abuse. The authors report a case of an unusual genital finding in a child which was suspected initially as being caused by sexual abuse but was subsequently determined to be a congenital anomaly. An external examination using a colposcope was useful in delineating the normal appearance of the tissues in question.     

Writing and marking examinations for paediatrics

Examinations are an essential element of medical education, which generates vehement debate but unfortunately a relative lack of rigorous critical analysis. There appears to be a background anxiety that research findings that might suggest an examination has been less than fair will lead to endless arguments with candidates who have failed that examination. It is a major responsibility of all those involved in examining to seek evidence of the fairness, reliability, and validity of the methods and the organisation of the tests. Computers have made analysis of results much easier. Access to shared banks of all types of questions and answer sheets should allow examiners to select the subject first and the assessment tool second but from a range of tested and continually modified questions which allow comparison of candidates' performance both in time and between institutions. The creation of examination materials and their evaluation must be considered as valuable an activity as research in academic life. There is little point in child health research if the advances in knowledge and skills that this generates cannot be shown to have been acquired eventually by present and future paediatricians.     

Writing and marking examinations for paediatrics.

Examinations are an essential element of medical education, which generates vehement debate but unfortunately a relative lack of rigorous critical analysis. There appears to be a background anxiety that research findings that might suggest an examination has been less than fair will lead to endless arguments with candidates who have failed that examination. It is a major responsibility of all those involved in examining to seek evidence of the fairness, reliability, and validity of the methods and the organisation of the tests. Computers have made analysis of results much easier. Access to shared banks of all types of questions and answer sheets should allow examiners to select the subject first and the assessment tool second but from a range of tested and continually modified questions which allow comparison of candidates'' performance both in time and between institutions. The creation of examination materials and their evaluation must be considered as valuable an activity as research in academic life. There is little point in child health research if the advances in knowledge and skills that this generates cannot be shown to have been acquired eventually by present and future paediatricians.     

What the paediatrician should know about paediatric and adolescent gynecology: The perspective of a gynecologist

Gynecological problems are common in children but training in this subject is rare during paediatric postgraduate education. Knowledge in this area is important for providing comprehensive health care to children. The article explores the gynecological examination of the child and common gynecological disorders in the paediatric and adolescent age groups. Routine examination of the external genitalia as part of a well-child physical normalizes the examination for the child and helps to inform the physician about the large variations in normal genitals. Many complaints can be dealt with by reassurance, while most others respond to medical therapy and can be dealt with easily by paediatricians. Both young children and adolescents respond positively when allowed to have control over the tempo of the interview and the examination. A positive experience associated with a genital examination will help to open lines of trust. This along with nonjudgmental, open communication, will create educational opportunities to enhance a responsible transition from child to young adult.     

The diagnosis and care of transsexual children and adolescents: a pediatric endocrinologists' perspective

The normally developed child whose gender identity and anatomic sex disagree is referred to as a transgendered child, or as used subsequently in this text, a transsexual. The ramifications of this disagreement include a high risk of psychiatric conflict and maladjustment, for both the individuals themselves and their families. Despite the efforts of researchers to systematically study this group of children, many fundamental questions remain. In many respects, those lingering questions are shared by patients with physical intersex who have been cared for by pediatric endocrinologists. In intersex and transsexual patients, the medical community, although sincerely interested, remains wary to intervene in ways that may lead to further inconsistency between anatomic sex and adult gender identity. A perspective on the problems of differentiating permanent from transient gender identity, some thoughts on the most appropriate management of the transsexual child/adolescent as well as remaining questions are discussed. Both the flexible and therefore potentially misleading gender identity in children and the medical communities' pledge to first do no harm (primum non nocere) have regrettably fostered disharmony between gender disordered patients, their families, and the practitioners who want to help them.     

Sexueller Missbrauch von Kindern

Medical involvement in the diagnosis and treatment of child sexual abuse (CSA) has a well defined role within a multidisciplinary concept. Due to the frequency of normal anogenital findings in victims of CSA, forensic aspects are of limited value in diagnosing CSA. In selected cases however, medical findings may play an important role in corroborating a child's history. Correct evaluation of normal findings, normal variations, and abuse related findings and several differential diagnoses require a sound pediatric gynecology background. In some cases physical sequelae of CSA (injuries, infections, and pregnancy) need to be diagnosed and treated accordingly. The majority of abused children have an altered and distorted body image. It is of paramount importance to reassure the child that his body is normal, physically undamaged, intact or that it will heal (“primary therapeutic aspect of the examination”). Thus the medical examination has an enormous potential to incorporate a therapeutic message into the diagnostic procedure. By communicating with the psychosocial und jurisdictional system, physicians may initiate proper child protection and therapy. Therefore medical evaluation of sexually abused children must be integrated into a multiprofessional concept of child protection.     

Colposcopic genital findings in prepubertal girls assessed for sexual abuse

After the introduction of the colposcope for the examination of children suspected of being sexually abused in Leeds, a study was undertaken to describe the findings in detail. A total of 109 consecutive prepubertal girls, mean age 70.4 months were assessed including colposcopic genital and anal examination, and peer group review of reports and photographs. Fifty nine children had signs consistent with blunt force penetrating trauma (hymenal transection/major notch, scar, or hymenal attenuation). Transections were encountered most commonly at 6 o'clock (directly posterior). In 46 the hymenal orifice was gaping with thigh abduction only and in 47 the hymenal orifice transverse diameter was greater than 4 mm on labial separation. Overall, physical findings were commonly present and in only two cases were no signs recorded. Non-specific and frequent findings included patterns of labial and introital reddening. Supportive hymenal signs including swelling, rounding of edge, thickening, distortion, and loss of symmetry were common. Labial fusion was present in 20. Urethral dilatation with labial separation was noted in 14. Physical findings including normality are consistent with abuse and even minor anogenital signs as well as negative findings should be documented. Colposcopy and photography are valuable tools in peer review, teaching, and case management.     

Use of the motor performance checklist to study motor outcomes in 5-year-olds

Aim:   To report findings about the Motor Performance Checklist (MPC) for 5-year-olds, a simple 12-item instrument for assessing gross and fine motor skills, in a research study of neurodevelopmental outcomes after neonatal events.
Methods:   We trained 10 examiners to use the MPC in a study of the outcomes of neonatal jaundice and dehydration in 339 5-year-old children. We compared MPC scores with those on the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R), the Beery–Buktenica Developmental Test of Visual-Motor Integration-Fourth Edition (VMI-4), and a standard neurological examination, and compared failure rates on each MPC item across examiners. Parent concerns about their child's development were addressed using the Parent Evaluation of Developmental Status (PEDS).
Results:   Children who 'failed' the MPC had 7–10 points lower mean scores on the WPPSI-R subscales ( P  = 0.001), 9–10 points lower mean scores on the VMI-4 subscales ( P  = 0.001), and were almost twice as likely to have a 'questionable' neurological examination score (adjusted OR 1.86, 95% CI 1.00–3.53, P  = 0.005). On the PEDS, only the concern about the use of arms and hands was significantly associated with MPC failure. We found significant sex differences on four of the 12 MPC items. We also found differences in failure rates by different examiners.
Conclusions:   MPC scores correlated with other measures of neurodevelopment. Because of different failure rates across examiners, examiner terms need to be included if it is used in research studies.     

Preadoption opportunities for pediatric providers

International adoption pairs the most vulnerable and high-risk pediatric population with the lowest risk parent group. International adoption also presents unique and rewarding challenges for primary care pediatricians. After receiving information from the medical reviewer, a parent must determine whether or not this child is "their child." The position of the medical reviewer is to provide the family with as much information as possible about the health status of the child by explaining the terminology in the report and assessing the photograph or videotape. It is also the reviewer's job to guide the parent's expectations of the adoption by explaining the inherent differences in the development of children in institutions. In the preadoption phase, we must remember that our ultimate goal is to aid in the permanent placement of a child with a family that has realistic expectations and is well prepared to aid that child to reach his or her fullest potential.     

Do no more harm: The psychological stress of the medical examination for alleged child sexual abuse

Aim:   Currently, there is some controversy that the medical examination following allegations of child sexual abuse may further traumatise the child. Access for children to appropriate care may be hindered if decisions about referral are influenced by personal beliefs, rather than by recognition of the potential health and psychological benefits of the assessment. We aimed to study the expectations and emotional responses of children and their parents to the medical examination.
Methods:   We conducted a prospective quantitative and qualitative study at the Children's Hospital at Westmead. Participants completed questionnaires pre-examination and post-examination, including Children's Anxiety and Pain Scales. Clinicians recorded a Genital Examination Distress Scale and a questionnaire about potentially prognostic variables.
Results:   Parents found the medical examination significantly less stressful than they had anticipated. They highlighted the importance of being involved in the process, the child's reaction, staff attitudes and the doctor's explanations. Although most parents expected that the medical would be stressful for their child, this did not correlate with the children's reports of feeling scared beforehand. Increased parental and child distress were significantly associated with the child being 12 years or older. The type of abuse was not significantly linked to any of the parent or child self-reports.
Conclusion:   Our findings indicate that the medical examination is not as stressful as expected and support the recommendation that timely medical assessment by appropriately trained professionals should be offered for all children following allegations of sexual abuse.     

Evaluation of sexual abuse in the pediatric patient

Evaluating a patient for suspected child sexual abuse can be daunting for many pediatric primary care practitioners. The consequences of misdiagnosis can be devastating. Knowledge of common clinical presentations, both physical signs and symptoms and behavioral changes, is paramount. Sexual abuse allegations must be reported and investigated by child protection agencies or law enforcement. Practitioners must be aware of when and how to report suspected child sexual abuse, in addition to having a basic understanding of the medical examination and findings. With a caring, knowledgeable, and sensitive approach to allegations of sexual abuse, the practitioner can assist the child and his or her family through this very difficult process. J Pediatr Health Care. (2000). 14, 93–102.     

Encopresis

A careful history and physical examination will help to differentiate between encopresis with or without constipation and fecal incontinence caused by anatomic or organic disease. Most children with encopresis with or without functional constipation require no or minimal laboratory workup. Successful treatment of encopresis requires a combination of parent and child education, behavioral intervention, medical therapy, and long-term compliance with the treatment regimen. The conventional treatment approach consists of behavior modification and laxative for children with encopresis with constipation and behavior modification alone for the few children with encopresis without constipation. Almost every patient will experience dramatic improvement in encopresis. Recovery rates are 30% to 50% after 1 year and 48% to 75% after 5 years.     

The diagnosis of child sexual abuse.

OBJECTIVE--To examine how the history, psychological evaluation, medical examination, and child's response to the examination contributed to a diagnosis of child sexual abuse by an interdisciplinary team. DESIGN--Patient series. SETTING--Subspecialty clinic for evaluating prepubertal children alleged to have been sexually abused. PARTICIPANTS--One hundred thirty-two children alleged to have been sexually abused and their parents or guardian, evaluated consecutively in a subspecialty clinic between September 1989 and June 1990. MEASUREMENTS/MAIN RESULTS--A social worker interviewed the parents, a psychologist interviewed the child, and a pediatrician obtained a medical history and examined the child. Parents completed a Child Behavior Check list and the child's response to the physical examination was noted. Both a disclosure by the child and abnormal physical findings were significantly and independently associated with the team's diagnosis of sexual abuse, whereas the presence of sexualized behavior, somatic problems, and the child's response to the examination did not make an additional contribution to the diagnosis. CONCLUSIONS--The findings support the need for a skilled psychological interview and a medical examination of a child alleged to have been sexually abused to make the diagnosis of sexual abuse. An interdisciplinary team appears to be a valuable approach for evaluating these children and their families.     

Evaluating child sexual abuse

We have learned much about the medical evaluation of suspected child sexual abuse during the past 2 decades. The physical examination still holds an important place in the evaluation but is secondary to a well-performed history. As the evolving literature increases our understanding, the relevance of various anatomic appearances of the prepubertal and pubertal genital examination will certainly become even clearer. The physical examination rarely is diagnostic by itself, with more than 92% of cases failing to demonstrate either acute or chronic signs of injury. Thus, the 1994 quote by Adams and colleagues, "It's normal to be normal," continues to ring true, now supported by a growing body of pediatric literature.     

Colposcopic genital findings in prepubertal girls assessed for sexual abuse.

After the introduction of the colposcope for the examination of children suspected of being sexually abused in Leeds, a study was undertaken to describe the findings in detail. A total of 109 consecutive prepubertal girls, mean age 70.4 months were assessed including colposcopic genital and anal examination, and peer group review of reports and photographs. Fifty nine children had signs consistent with blunt force penetrating trauma (hymenal transection/major notch, scar, or hymenal attenuation). Transections were encountered most commonly at 6 o''clock (directly posterior). In 46 the hymenal orifice was gaping with thigh abduction only and in 47 the hymenal orifice transverse diameter was greater than 4 mm on labial separation. Overall, physical findings were commonly present and in only two cases were no signs recorded. Non-specific and frequent findings included patterns of labial and introital reddening. Supportive hymenal signs including swelling, rounding of edge, thickening, distortion, and loss of symmetry were common. Labial fusion was present in 20. Urethral dilatation with labial separation was noted in 14. Physical findings including normality are consistent with abuse and even minor anogenital signs as well as negative findings should be documented. Colposcopy and photography are valuable tools in peer review, teaching, and case management.     

External diseases of the eye.

The child presenting a red, tearing eye can pose a dilemma for the pediatrician. A good history and a careful systematic examination using good light and magnification should lead the physician to the proper diagnosis. The child with no complaints other than discharge probably has a conjunctivitis, while the child with photophobia and a scratchy sensation should make one search for either a foreign body or a corneal problem. Fluorescein dye is invaluable in outlining a corneal scratch, abrasion, dendritic ulcer, or bacterial ulcer; and the use of smears and cultures can help pinpoint the exact cause of the patient's difficulties and help in choosing the proper medication. The care of the patient with a red eye may be difficult; but when properly done, it can be a source of great satisfaction to both the patient and the physician.     

Current debates in child sexual abuse

This report debates some of the topics around sexual abuse that appear to be causing some difficulties to practitioners. The incidence is mentioned and the importance of the history from the child is emphasized. Reasons why a child should receive a medical examination together with when the examination takes place, who should carry this out, and whether this should be one or two practitioners. The consent to the examination and timing of it are also debated as is the nature of the examination, and the need for good and appropriate documentation, and photography of one sort or another. The examination positions are discussed as are the clinical findings and sexually transmitted diseases.     

Inter-rater reliability in the medical diagnosis of child sexual abuse

Objective: To examine inter- and intra-rater reliability in the assessment of genital findings in cases of suspected child sexual abuse. Methodology Colposcopic photographs of the external genitalia of 70 female children were independently assessed by child sexual abuse teams in Auckland and Sydney. For the Auckland centre, intra-rater reliability was assessed by making a second independent assessment 6 months following the first. Reliability was quantified using per cent of agreement and Cohen's Kappa statistic. Results There were high levels of inter- and intra-rater agreement. When photographs were classified as normal/non specific or strongly indicative of child sexual abuse, there was 93% agreement between the Auckland and Sydney teams with a kappa score of 0.70. For the two separate ratings made by the Auckland team there was 94% agreement with a kappa score of 0.75. Conclusions The high levels of inter- and intra-rater agreement obtained in this study were reassuring. The results obtained compare favourably with the results of reliability studies in other areas of medical practice.     

Developmental dysplasia of the hip: definition, recognition, and prevention of late sequelae

When a child presents with a dislocated hip after the walking age, parents are upset, pediatricians are distraught, and lawsuits often follow. The prevention of late presentation is a goal that all practitioners should strive for. However, at this time, using current diagnostic techniques, the late presentation of DDH can be minimized but not eliminated. The AAP Subcommittee on DDH has estimated that approximately 15% of DDH at birth is not detectible, even by experienced examiners or ultrasonographers. In addition to preventing the late presentation of a developmentally dislocated hip, the prevention of premature degenerative arthritis of the hip secondary to developmental subluxation and acetabular dysplasia is equally, if not more, important in terms or morbidity and cost. It is hoped that the identification and treatment of babies with DDH at birth will have the added benefit of decreasing the incidence of degenerative arthritis of the hip in adults. As the key to early detection remains repeated, careful examination of the infant in the first year of life, it is imperative for practitioners to become as skilled as possible in performing the exam. Unfortunately, medical school curricula and pediatric and family practice residency programs often are deficient in teaching the neonatal hip examination. Strategies for clinicians to improve their examination technique include asking a pediatric orthopedic surgeon to demonstrate the examination in their nursery or attending one of the AAP courses on DDH. Starting a formal DDH screening program in the nursery is another option, using few screeners to maximize their experience. Nurse practitioners, physician's assistants, and physiotherapists could be used in addition to physicians. Having a child present with a developmentally dislocated hip after the walking age is not malpractice if the child has had repeated careful examinations. It is important to document the examinations in writing, rather than placing a check mark next to "musculoskeletal" or "hips" on standard, pre-printed exam forms. The best documentation is a handwritten note that states "the hips are stable and there is wide symmetrical abduction" at every well-child visit. At this time, careful, repeated physical exam supplemented by ultrasonography or X-rays for babies with risk factors is our best strategy to minimize the late presentation of DDH.     

Bruising: the most common injury in physical child abuse

Bruising is a commonly sustained injury in childhood, and thus is often overlooked during examination. However, it is the most common abusive injury, and may indicate severe internal injury, or precede catastrophic injury. Knowing which bruises warrant further investigation is vital to protect the child. A careful history, including developmental stage, past medical and social history followed by a full top to toe examination is required. Evidence highlights that some patterns of bruising warrant further investigation. This includes bruising in young, immobile infants, or bruising to the cheeks, ears, neck, trunk, genitalia or multiple bruises from a single incident, particularly in a distinct pattern or accompanying petechiae. Full assessment includes obtaining high quality clinical photographs of the bruising, exclusion of underlying bleeding disorders, consideration of differential diagnosis, and assessment for occult injury. The latter should include a skeletal survey in those aged less than two years, and computerized tomography of brain and full ophthalmology examination for those aged less than one year. Discussion with senior colleagues, consideration of the safety of the child, and clear communication with the family is vital throughout this process. Acting promptly and appropriately when concerning bruises are found may be the only opportunity to protect this child from further harm.